Pancreas‐preserving duodenectomy after living donor liver transplantation for invasive cytomegalovirus disease

Abstract

CMV infection plays an important role in the postoperative course following solid organ transplantation. We present the case of an 11-year-old male patient who underwent LDLT due to severe hepatopulmonary syndrome and biliary cirrhosis. Four weeks after LDLT, he developed persistent GI bleeding and was subjected to repeated endoscopic treatment and radiological arterial embolization to stop the bleeding from duodenal ulcers. Diagnostic workup was negative for CMV disease. Because the bleeding persisted, surgical treatment was indicated, and a pancreas-preserving duodenectomy was performed. Immunohistochemical staining of the surgical specimen demonstrated diffuse endothelial infiltration by CMV. Despite ganciclovir treatment, the patient developed new erosions in the jejunal mucosa and melena; ganciclovir was discontinued, and foscarnet was started, resulting in clinical improvement and the cessation of bleeding. This case highlights the technical aspects of performing a complex upper GI resection in a patient recently subjected to LDLT, taking care to avoid injury to the previous liver graft anastomosis and restore GI continuity. Moreover, CMV tissue-invasive disease compartmentalized in the GI tract may be difficult to diagnose, as indicated by the negative results of antigenemia and PCR assays and endoscopic superficial mucosal biopsies.

Pancreas-Preserving Total Duodenectomy: A Systematic Review

“…In terms of reconstruction, Tsotios and Sarr [8] recommend performing the pylorojejunostomy first for 2 reasons: the best evaluation of the appropriate length and tension of the neoduodenum and the site for the reimplantation of the ampulla with correct positioning of the retropancreatic mesentery and to avoid improper manipulation of the higher risk suture (ampullo-jejunostomy). All the surgical techniques described in the articles call for reconstruction in 1 single jejunal handle, with the exception of Vincenzi et al [37] whose patient underwent DTPP after living donor liver transplantation for invasive cytomegalovirus disease using 2 handles. In general, most patients underwent pylorojejunal/gastrojejunal (neoduodenum) anastomosis according to Billroth I, although Imamura et al [6], Kalady et al [17], Wig et al [25], and Benetatos et al [26] performed Billroth II.…”

Colon perforation due to antigenemia-negative cytomegalovirus gastroenteritis after liver transplantation: A case report and review of literature

“…Although there have been reports on cases with gastrointestinal perforation due to CMV gastroenteritis, this complication is extremely rare after a solid organ transplantation[2,3]. Recently, there was a report showing that CMV infects vascular endothelial cells and causes ulcers and perforation locally in the intestinal mucosa after solid-organ transplantation[21].…”

“…Although CMV infection tends to occur at least three week after transplantation[3], patients taking immunosuppressive drugs before transplantation may be affected earlier[6].…”

“…The CMV-antigenemia (AG) positivity rate at the onset of gastroenteritis has been reported to be approximately 20%-30%[1]. Although gastrointestinal perforation due to CMV gastroenteritis is not uncommon[2], such an occurrence has rarely been reported after organ transplantation[3]. Autoimmune hepatitis is an autoimmune disease that commonly develops in middle-aged or older woman and usually causes chronic and progressive liver damage.…”

Stricturing CMV enteritis in an adult liver transplant recipient

“…Series reporting episodes of CMV enteritis demonstrate about a 40% incidence of small intestinal disease, with the esophagus and colon compromising an equal percent of cases [8]. To our knowledge, there is one report of CMV enteritis an adolescent liver transplant recipient, who presented with duodenal bleeding requiring pancreas preserving duodenectomy but no stricture [9]. The reports of intestinal CMV infections in children emphasize that all patients had significant causes for immunodeficiency, such as HIV, prematurity, or age less than 6 months.…”